60Y/M with ?Viral pyrexia with COPD

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A 60yr old male patient came to the casualty with c/o fever since 2 days a/w chills

HOPI - 

Patient was apparently asymptomatic 2 days back then he developed high grade  fever associated with chills  

No H/O rash

No H/O neck stiffness

No H/O vomitings and pain abdomen

No Burning micturition

Past History - 

K/C/O Asthma/Copd since 10 years

Not a k/c/o HTN,DM,TB,CAD, CVD 

Personal history -

Diet - mixed

Appetite - Normal 

Bowel & bladder movements - regular 

Occasional alcoholic

Family history - not significant

On Examination 

patient is c/c/c

Clubbing of fingers-present

No pallor , icterus , cyanosis , lymphadenopathy , edema

Vitals -

Temp - Afebrile

PR - 110bpm

BP - 150/90 mmHg

RR -22 cpm

SpO2- 92%@RA

Systemic examination -

CVS - S1 S2 heard

RS -BAE present

P/A - soft , non tender. 

CNS - NAD 

Provisional diagnosis - 

Viral pyrexia 

with COPD

INVESTIGATIONS:

 

TREATMENT:

TAB.AUGMENTIN 625MG BD

TAB.ECOSPIRIN-AV 75/10 MG OD

INJ.PANTOP 40MG IV BD

TAB.PCM 650MG PO TID

IVF-NS@UO+30ml/hr

NEB with Ipravent and budecort 

INJ.NEOMOL 1GM IV SOS (IF TEMP >101°F)

PLENTY OF ORAL FLUIDS 

TEMPERATURE CHARTING 4th HOURLY